Clinical Case Symptomatic CVD without varicose veins <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllAnswers /> Clinical Case Symptomatic CVD without varicose veins

A 39 years old female patient, presented with symptomatic right lower limb. She noticed the symptoms 5 years ago. Signs and symptoms -Tenderness -Local pain Worst at the end of the day and during standing Symptoms are relieved with limb elevation She had 3 pregnancies 2005, 2011 and 2013 Symptoms started 5 years ago after the 2nd pregnancy She is feeling worse after her last pregnancy 3 years ago

Family history Her mother has spider veins Medical history None Medications Surgical history Minor foot surgery Social Alcohol occasionally

Physical examination Both lower limbs were warm and well perfused Distal palpable pulses No prominent varicosities, skin changes or ulcers Motor and sensory were intact Feeling of swelling but not measurable difference between the lower limbs Athletic type, moderate activity at home and work BMI 22

No varicose veins

Revised VCSS: 3 Pain None: 0 Mild: 1 Moderate: 2 Severe: 3 Pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning) Occasional pain or other discomfort (ie, not restricting regular daily activity) Daily pain or other discomfort (ie, interfering with but not preventing regular daily activities) Daily pain or discomfort (ie, limits most regular daily activities Use of compression therapy 1 2 3 Not used Intermittent use of stockings Wears stockings most days Full compliance: stockings Vasquez MA, et al. Revision of the venous clinical severity score: venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg 2010;52:1387–1396.

GSV reflux in the lower thigh The GSV was not dilated. There were no intraluminal findings to indicate previous Injury or thrombosis. No tortuous segments were found.

GSV reflux at the knee and upper calf Long reflux duration induced by calf compression Labropoulos N, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793–8.

GSV diameters in the lower thigh, knee and upper calf

GSV increase wall thickness at the area of reflux 17MHz linear frequency transducer – 0.9mm axial resolution

C0S EP AS PR No varicose veins GSV reflux 4.6mm 4.2mm No varicose veins GSV reflux SSV and deep veins were normal No venous obstruction 4.2mm 4.1mm 6.2mm 1.2mm 3.4mm 1.7mm 3.3mm 0.9mm GSV reflux extended from the pre-terminal valve to upper calf. A small 1st order and a few 2nd and 3rd order tributaries had reflux. 2.5mm 3.0mm

Treatment plan Follow-up The patient has subclinical segmental disease. She may benefit from -Elastic compression stockings Follow-up She should be followed-up to determine the effects of treatment. If the patient feels better and tolerates the treatment she should continue the above management. Treating such patients with endovenous techniques is controversial and no guidelines exist for their management.